Keep Calm and Take Vyvanse

This is the shortest blog post I have ever written. Please enjoy the epigrammatic and succinct composition of the accompanying image.

A Response to a Reader's Question about Medication.

I got a comment just now from a reader which included questions about their medications. They take methylphenidate and Strattera and are wondering about the length for duration, or of the overall effectiveness of their medication.

As a non-professional, I responded as follows, and hope that it clarifies my own understanding of medication as it relates to ADHD treatment. I would be very interested to hear from readers their thoughts on my perspective, and the advice I gave...

I wrote (I have modified it slightly for clarification below):

"Have you spoken with your doctor or psychiatrist? Methylphenidate and the amphetamine class of psychostimulants work for some and don't work for others - it can't really be predicted, depends on the individual. There are dosage aspects, metabolism issues, concurrent medication useage, and a host of other factors involved, not to mention your own personal level of change or stress due to situational factors (New job, school, city? Change in relationship status? Problems in your personal life? Are you getting sufficient sleep?)

Strattera didn't really work for me by itself, and I no longer take it. But I do take another NSRI class medication - buproprion (trade name Wellbutrin). Some of the NSRI meds can be useful in reducing some of the anxiety which may be brought on by taking the stimulants and may assist executive function, or so I understand.

What form of methylphenidate are you taking? Long release like Concerta or Adderall XR, or short release, like short release Adderal or Ritalin?

A good psychiatrist with a clear understanding and training in psychopharmacology should help you tweak your medication. I would definitely speak with your doctor about this, though.

To get the most out of your appointment, I'd recommend the following:

Try to track your cognitive senses throughout a few days in a notepad - i.e. Your focus level between 1 and 10, attention.

Track your emotions also - and your reactivity, irritability, grumpiness, ability to manage transitions or to shift out of hyperfocusing without being too pissed off(!). Basically, your level of attention self-regulation.
Track impulsive behaviors - interrupting, acting out, moving on to an inappropriate task or activity, when you should be sticking with the one you're already on.

Also try to document your ability to get priority items done, your ability to be organized, your level of overall 'effective functioning' in various arenas of your life. That is, how well you are managing at work, home, school, parenting, relationships, hobbies, sports, personal care, etc...

Bring this tracking information to your doctor / psychiatrist and it should help them better understand how to help you find an effective medication regime. Hope that helps.

Note that I'm not a medical professional, so just take my advice as you see fit. All the best, and let me know how it works out!"

Mungo

All Kinds of Stuff and Things and Objects Found in Boxes

That's the best title I could come up with. It's 4 am, I just changed my daughter's very poopy diaper, and I figured that there's no time like the present to kick start my blog.

Just a heads up: Thumb typing on my Android might result in tortuous sentences, embarrassing hippopotatypos, and my 4 am brain might be prone to sentimentality - so be forewarned.

So. My house decided to get sold. So it is causing me* to pack up boxes of useful, important items, and boxes of useless, and seldom used crap. It is also causing me to wander about trying to figure out what to do next. It made a painter come in today (yesterday?) and massage paint into its tired seams, corners, and surfaces, and is working very hard to make me replace several basement ceiling tiles. I'm staying in Toronto. Hopefully close by. But the market's good, I am led to believe, and so it seems like a good time.

I'm fond of this house. And I trust that it wouldn't try to get itself sold unless it knew I could manage it, with an overload of big-life-things. It will encourage potential buyers to loosen their purse strings and cause my bank account to breathe a deep sigh of relief, encourage me to order pizza, and do what it can to have me settle in to watch some YouTube documentaries, or even go out and meet another human and do things involving hamburgers or cheese or something.

In the meantime, I'm looking for a contract or a full time gig.

I also started the ball rolling yesterday afternoon on a twenty year old dream of mine to get my Masters in psychology. Do what you love, right?

Here's a few things - in case you've made it this far into my post - you may want to know about what I've figured out in recent months.

1. I'm stronger than I ever thought I could be.

2. Everyone is carrying a frighteningly raw crate full of hurt, terror, longing , desire, insecurity, and fear within their psyches - and it is always demanding to be opened, and exposed to the searing light, and fresh air. Find a way to own it. Find out how to become acquainted with it so that it becomes your strength, and not your burden. And all that... And be decent to everyone you meet. But have a plan to fuck off (multiple egress routes) at the first sign that they wish to fuck you over. :-)

3. I have too many pants, too many shirts, and altogether too much stuff.

And so it goes**.

I was interviewed by a reporter from NYC a couple of weeks back for an article she was editing on Adults with ADHD, and it was published, and it was cool to read my experiences online in someone else's voice.

Also, I was interviewed last fall for a book coauthored by a Canadian psychiatrist specializing in ADHD, and a Harvard Medical School psychiatrist. It's now out, and look forward to reading a little snapshot of the story of how my own train wreck of a life, crumpled self-esteem, and hopelessness was halted by an assessment, and a subsequent diagnosis of Attention Deficit Hyperactivity Disorder (Combined Subtype) and Generalized Anxiety Disorder, and competent treatment. And how it was transformed into a full-on awesome adventure of rediscovering life, my strengths, my buried feelings, and (did I mention?) my strength.

Oh. Hey. After 20 years of drinking 8 to 10 caffeinated colas, and coffees a day, I figured to stop. So 34 days ago, I chugged back a Diet Pepsi, and haven't looked back yet.

I don't drink. I don't smoke. I don't drink caffeine. But don't cross me, and don't test me. And expect the worst in a knife fight in a dark alley, if you ever try to start one with me. Metaphorically of course. I'm not a violent person. I'll simple pin you down, wait for you to calm down, and let you go with your pride intact, but without your weapon.

But dear readers - I beseech you. If I ever tell you I'm going vegan, or some such nonsense, you have my permission to chloroform me, tie me to a chair, and once I've woken up, to force feed me a huge medium rare Porterhouse steak au jus, smothered in horseradish, with a side of baked potatoes. Thanks in advance.

There's a boatload more I would love to write, but there's only so much my thumb will put up with, now that I've been thumb typing for an hour, and my eyes are tired.

And for some reason I have Motörhead's Ace of Spades roaring through my head, so I will paraphrase Lenny (the singer) and implore you to remember the following:

"...and don't forget the McFlurry... "

Actually, here. Listen.

Going back to sleep.

Love and danger,

Mungo

*Note that the house appears to have agency in my post. This literary device was inspired by the beautiful writings of Kurt Vonnegut.

** This animistic narrative transition is brought to you by the 116 occasions Kurt Vonnegut in which he used this phrase in his fascinating and raw book Slaughterhouse 5, a title inspired by the name of the building ("Schlachthof-fünf") in which he and other Allied prisoners were kept. In this building, they took refuge and consequently survived the horrific massive incendiary bombing (total of 200,000 incendiary devices) of Dresden, Germany in WWII which resulted in an enormous firestorm which engulfed 12,000 dwellings, killing in one night 20 to 25 thousand civilians, and which was brought to you by Marshall of the British Air Force, Sir Arthur Travers 'Bomber' Harris, AOC Bomber Command, and signed off upon by Prime Minister Sir Winston Churchill.

29 Quick Tips To Chew Upon for Adult ADHDers

A few useful tips for adults with ADHD to chew on today:

1. Take time to meet with friends or a small group of adults. Don’t let yourself become isolated.
2. Exercise regularly. Find a partner, if possible, so you won’t forget to do it!
3. Find a quiet spot for yourself at home. Use it to relax, meditate & re-focus.
4. Use “pattern planning” to organize your days. Plan the same activities for same time each week.
5. Do not over-schedule your time. Learn time management skills & be realistic.
6. Make a list of ideas & “to do” items to free your mind for concentrating.
7. Review the items on your list, prioritize them, & cross of all you have accomplished.
8. Close your door, if possible, when you don’t want to be disturbed.
9. Build “flex time” into your schedule to allow for the unexpected.
10. Set up a study area away from distractions & set specific homework times.
11. Build in “break times” during long homework assignments. Use a timer.
12. Do weekly bag dumping after your work or school week. Dig deep & get out all that old “stuff”.
13. Devise a calendar of long-term assignments and projects to be carried in your notebook.
14. Get daily exercise. Walk or bike. Exercise helps to keep you & your brain focused & energized.
15. Learn how to be healthy. Eating good food helps to keep you focused, active & in a good mood.
16. Make time for frequent review & tossing of old papers. Set small goals of a few papers each time.
17. Mark what you read with a highlighter or flag important areas with small, colorful “post-it”s.
18. Tackle time-consuming & detailed projects in stages. Develop a plan before you begin.
19. Use your high productivity hour for your most important project & most difficult homework.
20. Get educated about AD/HD. The more you learn, the more you can work WITH it & not against it.
21. Keep a family calendar at home or online using a shared electronic calendar (e.g. Google Calendar).
22. Design systems & guidelines for the family that is mindful of each person’s needs.
23. Avoid morning chaos by getting everything “ready to go” for work & school the previous night.
24. Become well educated on co-morbid / co-existing conditions.
25. Plan regular friend & family outings. There are many activities that are low cost or free.
26. Take a “team” approach to problem solving.
27. Work together to get organized. Chunk down tasks into small steps for those with AD/HD.
28. Set a scheduled family time every few months for tossing unused items, old clothes & old newspapers.
29. Work toward a better understanding of friends & family members with AD/HD. There are gifts in each of us.
    

Cheers,

Mungo

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I'm Back, Baby, I'm Back - Vyvanse and Adult ADHD

Well, hello everybody. Yup. It's me. Yup. I know. Nearly 3 months. Nope. I wasn't in prison. Nope - didn't get lost in the woods. Nope - not in Guantanamo Bay, either. Nope - didn't enter a fugue state, turn up at a McDonald's in Oregon speaking Dutch, claiming not to know my own name. Nope - not kidnapped either.

I've been here and there getting things done, and I think I was kind of waiting to get attuned to a new job (a contract position), new medication, and a new daughter (she's 3 weeks old and now our 2 1/2 year old boy is a big brother...) before writing more about my progress and journey.

I'm here and in good spirits. In fact, the best I think I've ever been in.

The last three months have been great - in large part to the new medication I'm on. I returned to the clinic I'd initially had my diagnosis at, and saw a psychiatrist who was recently the president of the Ontario Psychiatric Association for a second opinion. He was terrific. So I went off Strattera, and as soon as it cleared from my system, started taking a drug called Vyvanse to manage my ADHD symptoms. For me, it was nothing short of incredible. I started at 20 mg, and have now moved up to 60 mg. I initially called it my James Bond 007 medicine. More on that later. In fact, Vyvanse works so well for me that I almost feel that I wasted nearly a year on Staterra.

Vyvanse is essentially an extended release formulation of Adderall and was approved only in January of this year in Canada. It has been around in the U.S. for much longer, and of course is essentially Adderall - a well-proven psychostimulant which has been around for decades. What's different is that some clever chemists attach a lysine (amino acid) molecule onto the dexamphetamine, and ended up with the delicious-sounding lisdexamfetamine dimesylate. This pharmaceutical processing makes Vyvanse a prodrug - a pharmacologically inactive compound that require in vivo (in your body) conversion to release therapeutically active medications.

The prodrug aspect of Vyvanse achieves a couple of goals:

The first is to prevent the abuse of the drug, because the only way you can metabolize it into the stimulant dexamphetamine is by first orally ingesting the medication (gulp) and thereby allowing the drug to pass through your small intestine into your blood stream. It is on the surface of your red blood cells - after it has been absorbed through the microvillae on your small intestine's wall - that the lysine is cleaved away from the dexamphetamine, thus making it 'bioavailable'. So this precludes someone snorting the pill, or injecting it into their arm to get a quick rush. But from what I understand, even if you took a lot of the pills, their is still somewhat of what I call a metabolic turnstile, such that your body can only metabolize a certain amount of the prodrug at a certain maximum rate - so you wouldn't get an abuse-worthy amount of meds in your system if you tried.

The second goal is related to my last point, in a way. The medicine is metabolized at a given fixed rate - based on your system's 'throughput' rate and in this case, the psychostimulant is released in your bloodstream body over a period of up to 14 hours. This sustained, smooth release allows for full coverage throughout your waking day into the early evening - and doesn't give you a crash at the end.

And so I return to the James Bond 007 reference from earlier. The first week I was taking Vyvanse, I noticed clear and positive cognitive effects, and virtually no physical side-effects (other than some minor dryness of my mouth, which passed after a few days). I could focus appropriately and without effort. No longer did I unintentionally scoot from thought to thought, activity to activity, daydream to daydream and from topic to topic during a conversation. I stayed on track. I felt as though my situational awareness was heightened - yet controllably so. You can imagine a scene in a James Bond movie, or in a movie like the Bourne Ultimatum where the secret agent is in the middle of a mission requiring his full attention. This attention comes from a combination of extensive training, rehearsal, knowledge, physical fitness, mental acuity and a strong sense of confidence. Thus James Bond walks with sureness, certainty, does not get sidetracked, and goes about his dashing, albeit lethal business. Although in my case, the business does not involve blowing up embassies, shooting bad guys and rescuing wailing dames from the grips of deranged sociopathic baddies. Generally speaking.

Within a few weeks I stopped being so aware of my increased focus - which makes sense. I think I just got used to this improvement. But cognitive effects aside, the way I know that Vyvnase is really working for me is with my external environment, i.e. the world around me, the things on which I have agency and the world in which I take action.

My personal Action List, comprising all the large and all the minor things I need to complete in every arena of my life, which I have been diligent in gathering and maintaining over the past year, has decreased in length. Now it isn't often that a decrease in length is considered a significant selling point for a medicine (ba-dum-CHING!), but I have been able to tackle the really big projects on my list and been able to remove a lot of items from my list. I am acutely, almost painfully aware that I have a life-time of deficit to catch up on, and so I've been running at full steam to get things done - propelled both by excitement and happiness and indeed by a newly found focus. I can see the list diminishing, and with each item crossed off, I get a little bit stronger and gain a little bit more pride in myself. I suppose you could say my self-esteem is improving.

And as a result of going on Vyvanse, I've had a few insights. One of them is that I've learned a large part of my difficulty with getting projects done was a combination of 1) my poor (neurobiologically influenced) pre-conscious attention modulation resulting in me rapidly turning away (without being aware of this) from thoughts of daunting, uninteresting complicated or mundane tasks, and 2) a life-long paucity of experience and learned competency with organization, planning, and coping skills. That is, 'was never good at it, so never learned it, and so now has to learn it'). And between my deficient and neurobiologically impaired attentional capacities, and my deficient executive-functioning skills lies a set of deeply engrained core schema beliefs about my ability to sustain and achieve real change and to attain a competent sense of agency & control over my environment, personal & work life, and relationships with others.

Another insight is that it would have been really (REALLY) nice if I'd been identified as having significant attentional problems when I was a child. Scanning through my grade 4 report card, I read the following note:

"He is is obviously a capable boy as his contributions at group time and comprehension reveal - oral, reading. He is also quite fluent. This ability is not reflected however in his written work which appears often hastily completed. At times he is disruptive to those around him and as well he's easily distracted. His projects cover a lot of material but lack organization. Record keeping was accurate but could have been presented in a neater fashion."

So I was a capable boy, engaged and interested in working in a group, and demonstrated good oral, verbal and reading abilities. I was seen as disruptive (i.e. impulsive). Easily distracted. Hastily finishing work due to poor organizational and time management skills. Demonstrated lower than normal executive functioning as seen in my poorly-organized written work (as compared to my otherwise notable conceptual abilities). Messy record keeping indicative of comorbid dysgraphia. I'm sorry - HOW did my parents, teachers, guidance counselors, and other involved professionals NOT see ADHD as a strong possibility, or at the very least, refer me for professional assessment? Forget most of the items - let's assume all of the adults were half-asleep, hungover, or preoccupied with much more important things. What about the 'disruptive and distractible' parts? C'mon, folks. This wasn't the 1950s. This was the late 1970s and 1980s where guidance counselors were lining up, salivating at the opportunity to deal with my confounding combination of high potential, high intelligence, ravishing good looks and very low performance. And NONE of them saw a pattern in the chaos.

I mentioned earlier that I feel that I'm catching up with a lifetime deficit of getting things done, resulting in a long list Action Items which I need to take care of. And in the same way, I'm catching up and dealing with a bunch of emotional baggage. As I get healthier, and stronger and begin to get more perspective on my life, I begin to feel quite sad for me: for that strained, hopeless, frustrated, 'lazy and helplessly stuck' kid, that teenager, that young adult who suffered so exquisitely with all of the symptoms and the consequences of severe ADHD, combined subtype. And with that comes anger, and some wondering of how I managed to slip through the cracks. And yet at the same time, I recognize these feelings are natural - and that probably every adult who is late-diagnosed with ADHD goes through the same motions and emotions. And I hope to cover off more of this in future posts.

Switching gears somewhat, I have to make clear that while Vyvanse is working for me, it is truly 'to each their own' when it comes to medication. Physicians can use a variety of medications to treat and address the neurobiological / cognitive symptoms of adult ADHD. Each individual reacts differently to the various medications, depending on their metabolism, the expression of their genes, existing psychiatric comorbidties (anxiety, mood disorders etc...), confounding non-psychiatric conditions, other medications they are on, the ADHD subtype ('maybe' - this is something I came across recently), and the medication treatment regime and circumstances (titration rate, dose - not too little, not too much) - and effective, appropriate medical follow-up. And I'm sure there are several more factors I'm missing. The long and short of it is that medication works for ADHD, but you and your physician have to figure out the right medication through an empirical, educated, and trial-and-error approach.

And while the psychostimulants can work quickly - and result in remarkable changes in a person's life - the other pieces of the treatment arsenal have be brought to bear. The most effective treatment is a combination of medication, psychoeducation (i.e. learning about the disorder and the various techniques, coping strategies and skills that can provide relief) and psychosocial interventions including individual, group, or family counseling and ADHD skills coaching.

Those other pieces of the treatment arsenal will have to wait for future posts, though. It is late, and I am tired.

Hope you're all doing well. I'm glad to be back.

Mungo

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Drug Free and Waiting To Go on More Drugs...

Today is my first day without Strattera in my brain and blood for nearly 10 months. This way, I'll be able to go on Vyvanse (hopefully quickly) and be able to discern effectiveness without any conflicts due to another medication. I am very hopeful for this change.

Last week as I was coming off the medication, I have found myself excessively chatty (still happening). I noticed people 'casually' looking at their clocks or even saying "Well, I have some things I have to do now..." as my conversations ran on and on. My conversational skills are surprisingly interesting to me. No matter what others think.

Plus I have been quite fidgety. My right leg shakes up and down almost non stop. I should take up playing the spoons. Shaky shaky shaky. I shift in my chair a lot. I walk about during breaks to help me clarify next steps - which is a deliberate attempt to make explicit some working memory improvement techniques I am trying. I think it helps. I talk to myself quietly - "Okay, I must do X, Y and then Z..." and get it straight in my head before launching into a frenzy of productive energy. Were I not to plan it out, I'd likely launch into a frenzy of frenetic, unguided, unproductive activity...

Tomorrow I'm going to my family doctor to follow up on the psych consult I had recently, where the psychiatrist concluded that I should come off of Strattera and go onto Vyvanse. I have become inured to the fact that delays in my medical treatment will likely keep on happening. Heck, it has taken me 40 years to find out I have ADHD, so what's another few years?

Official prediction: I will go to my family doctor's office tomorrow and he will insist that I take a panoply of tests prior to getting the prescription (despite having had heart and blood tests for Strattera just 10 months ago). This will inevitably lead to a delay, and I won't get the Vyvanse prescription until a period in time when everyone will have their own private flying car, when all you will need to eat in a day is a single condensed pill with a glass of synthetic orange juice, and robots will have replaced the need for us to work.

I would rather lower my expectations and be surprised (i.e. get a prescription for Vyvanse immediately following my appointment tomorrow), than have high expectations and be disappointed, despite the fact that I oughtta know better by now.

I hope I'm wrong.

:-)

Cheerios,

Mungo

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Feeling Somewhat Irritable and Likely Projecting Upon Others

Next week I have my appointment to get changed over to Vyvanse. I'm looking forward to it, and feeling optimistic and excited. Well, that's what I'm feeling now.

But (I suspect) because I'm coming off the Strattera, and due to lack of sleep (staying up too late, possibly again due to titrating from 80mg to 30mg in less than a week) - I am especially grumpy, grouchy, touchy, irritable, and ever-so-slightly holier-than-thou today. So back the heck up (insert variation of wording as you wish) and get the heck out of my way.

So I wanted to make sure everything was in order for my doctor's appointment next week (and see if you can follow this):

Yesterday I checked in with my family doctor to see if the consulting notes and recommendation to change medications had been sent through to them, just so that I don't waste time driving a long way to another town to my family doctor. The assistant told me that it might have come through, but likely my doctor hadn't gotten to it yet as he'd been away and had a stack of papers on his desk 'this high'. I thanked her and she told me that she was sure he would get to it. But to be sure I phoned again today to confirm and she told me (as she checked my file while I was on the phone) that it had NOT come through. So I phoned the clinic back and the assistant there told me that the fax machine didn't work correctly on Monday so it hadn't gone through. She couldn't see that I wasn't blinking, and forcing a smile over the phone and so I asked her if she could try sending it again and that I'd call back in a few minutes to confirm that it sent okay. She said 'well, hold on... okay, there.' and it was sent. Just like that. Literally in seconds. So I thanked her, checked my family doctor's office and it had indeed gone through. I rolled my eyes and shook my head after hanging up.

And all the while I'm charged up and thinking 'goddammit how incompetent are all the people I'm dealing with this week?'. See, I am also working hard to push a project through in my new job and the third party contact is about as responsive and timely as a sloth on barbiturates. And no doubt, far less adorable.

Sure - I find customer service can be pretty lackadaisical at times, and realistically, most folks reading this would agree with me that at least a few of these situations involve folks who are not moving their derrieres in an effective manner, on time and under budget as it were (I'm a project manager, can you tell?).

And I could begin listing about a dozen more instances of irritating situations where people were taking their time getting things done... but I won't bore you with that. And anyway, it kinda would obscure my purpose for this post.

Here's my point: I obviously recognize that there is a common denominator to these scenarios. Moi. The one person who is consistently engaged in trying to solve a problem with all of these other unrelated people is little ol' cutie-pie me. Could it be that I'm projecting just a little bit?

"Our own projections are difficult to spot, first of all, because we don’t want to identify them as such: the whole point of projecting is to rid ourselves of something unwanted. While there are instances where people project their good qualities into others, ridding oneself of painful or unpleasant experiences is much more common."

Maybe it is because I'm coming to recognize an uncomfortable truth about myself, which is that often I'm the one who doesn't get around to things in a timely manner (if my lovely, and somewhat long-suffering wife is reading this she might agree!).

Charge me up with dopamine, norepinephrine, an intense emergency situation or anything that really commands (for some reason or another) my intense hyper-focused awareness and I'll blow through it like Evil Knievel on a motorbike. Like Han Solo in the Millennium Falcon. Like Chuck Norris in a bar fight. Go orbitofrontal cortex, go!

But so many times I am dimly aware of a set of important to-do tasks I'm leaving on the back burner, undone and unheeded.

"Projection is an unconscious fantasy that we are able to rid ourselves of some part of our psyche by splitting it off and putting it outside ourselves, usually into somebody else. While the initial process occurs outside of awareness, maintaining or insisting upon the reality of that projection often occupies our conscious thoughts. The process is usually distinguished by its focus and intensity."

So I note with considerable discomfort and with some shame that I am projecting to a large extent. I need to remind myself that I too don't always get things done at the speed of light. And that I don't always put other people's priorities on my own priority list. That I don't always empathize and spend my time ensuring others are considered. Or simply put: I am not always that considerate and responsive to the important people around me.

I guess 'owning my projections' means that I need to find a way to reconcile my own conflicting feelings and beliefs about myself and others. That is, why should others have to be completely efficient, competent and effective when dealing with me, but I can been inefficient, incompetent and ineffective when others deal with me? Is there a middle ground? There has to be a middle ground.

But in the meantime, I'm dealing with this in two ways: 1) biting my tongue while dealing with people when I need them to do something , and 2) making sure I diplomatically and considerately ensure my priorities are taken care of in a timely manner. This way I don't end up driving people away, and at the same time, make certain I take care of my needs so that I can get more healthy, grow up, do a good job at work and in other arenas of my life.

Comments are always welcome!

Mungo

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